When the BIG ONE Hits

When the BIG ONE Hits

Keep up with the latest on information governance as this key strategy emerges for addressing a myriad of information management challenges in healthcare. This blog will highlight the trends and opportunities IG presents for ensuring information is treated as an organizational asset.

By Vivian Thomas, RHIA, CHDA, CHPS, CPHQ, CDIP


Preparing for a disaster isn’t a matter of “if,” but rather a matter of “when.” The “big one” WILL happen and it will more than likely impact health information management (HIM) and other operations. There are several disaster events that healthcare organizations should anticipate and appropriately prepare for, including:

  • Massive earthquakes long anticipated in California
  • Destructive wildfires now experienced all too frequently in the western United States
  • Hurricanes and tornados causing destruction from the west to east coast
  • Cyberattacks destroying information or ransomware crippling an electronic health record (EHR) network
  • Extensive power grid failures eliminating linkage of EHRs, mobile device support, and communication systems

There are multiple potential causes of an EHR system outage, such as a natural disaster, cyberattack, or unanticipated hardware malfunction. Disaster preparedness for extended failure of the EHRs and other systems in healthcare settings is essential for every information governance (IG) program. The cost and risk impacts of an extended outage need to be anticipated and avoided. An EHR server failure involving a three-day outage in a large hospital network had an estimated operational impact cost of $1M per hour per day.

As steward of health information and data, the HIM professional incorporating effective IG processes can provide pivotal readiness for catastrophic disruptions of EHR system usage in hospitals. Collaborative involvement of HIM, IT, care providers, ancillary information managers, and leadership can facilitate readiness and recovery, ensuring the best plan is in place to manage such an event. These stakeholders should work together to solidify a plan and consider the following recommendations.

Disaster Plan Preparation
  • An emergency response network must be identified within the hospital, with a communication relay process
  • The disaster plan should be regularly updated and located in accessible care delivery locations as well as remote locations. The written plan, while archived electronically, should be accessible in hardcopy at strategic locations as a resource when systems are down.
  • The plan should include a full index and templates of medical record forms constituting the facility’s legal health record, both current and updated, with a nimble process for forms production during the EHR outage.
  • Continuity of Operations Plan should include a process for relay of orders and outcomes reporting for: pharmacy, clinical laboratory, radiology, therapy, dietary/nutrition. Also, a protocol for monitoring of patient location/bed control with movement of the medical record “chart” with patient transfers in hardcopy format.as established in backup mode. A process should be in place for daily in-house patient monitoring by unit with reconciliation of a complete medical record for each discharged/expired patient.
  • A preparatory resource is the Office of the National Coordinator for Health IT’s SAFER (Safety Assurance Factors for Electronic Health Record Resilience) guides (see CONTINGENCY PLANNING for guidelines in EHR downtime).
  • Treatment locations will shift if the central hospital facility is inaccessible or severely damaged in a disaster, and temporary treatment centers are created. The IG program should appropriately prepare these temporary treatment centers in the event of a disaster.
Back-up Readiness of HIM Systems
  • EHR systems must be backed up regularly and on schedule, verified with IT, and reported to IG workgroups. The data of the EHR should be segregated on a separate remote server. In recent EHR failure events, hospitals discovered the error too late and the back-up servers had not been isolated offsite from the crippled on-site servers. The back-up/isolation process will protect against the complete loss of patient information/data in potential server destruction disasters.
  • Paper-based medical record forms should be available in all patient care areas, alongside the disaster response policy and procedures.
    • HIM will ensure availability of current medical record formats, which match EHR-generated medical records. In a natural disaster, patient volumes are likely to spike—are medical record packets prepared for in-house and incoming patients?
    • Medical record documentation must align with the patient care workflow
      • Correct patient/identification number/hospital matching should be enabled
      • Documentation from clinical systems (verify application feeds), including networked devices, should be included
      • Medication administration and reconciliation is particularly challenged during outages—sans CPOE—and alert measures to prevent medication errors should be in place
    • HIM teams should be trained to regularly replenish the medical record forms during extended outages of an EHR system.
      • Immediate demand for photocopied medical record forms will occur, with scan image standards being maintained for the post-outage recovery
    • Teams should identify and prioritize essential medical records used operationally in care locations; key documents should be reviewed at least annually as part of the IG process between HIM and clinical lead staff representatives (e.g., Charge Nurses in Units and Emergency Departments)
    • HIM departments equipped with backup EHRs will continue the release of information (ROI) function during disasters, in some cases urgently, as patients and providers need access to laboratory results, radiology reports, clinical care summaries, and medication lists
    • As to HIPAA considerations, increases of ROI requests will be likely be Treatment or Operation authorized. In declared public health emergencies, Health & Human Services may issue a three-day waiver of HIPAA sanctions, specific to hospitals, as with Hurricanes Harvey and Irma (2017) and Hurricane Florence (2018) breaking the following protocols: Obtaining a patient’s consent to speak with family members/friends; honoring requests for facility directory opt out; distribution of privacy practices; patient’s right to privacy restrictions; and patient’s right to confidential communications.
    • HIM may play a key role in providing a health information exchange (HIE) network to find and transmit patient health information to requestors outside their health system, via offsite ROI or coding staff that have EHR viewing rights (“Read Only”), if the EHR system is crippled at the hospital site.
Practice outage training in the care environment

When practicing, make it real and ensure the plan is effective. Manual fallback processes need to be practiced regularly by all hospital staff.

  • Planned EHR downtimes are often scheduled on the third shift, after midnight, with intent to minimize impact/inconvenience. When the BIG ONE hits, there will be inconvenience—downtime simulation needs to be executed particularly with dayshift staff when operational impacts are most significant.
  • Workforce readiness: EHR outages have shown that newer physicians and nurses (i.e., grads trained only with EHRs) are unfamiliar with manual medical record documentation, including progress notes, order entry, Medication Administration Records (MAR), and vital signs. ‘Old school’ practitioners have been the only source of guidance to bridge the gap during recent outages by instructing newer staff. The world is soon a generation away from paper-based medical records.
Post-disaster eHIM business recovery

With the restoration of the EHR system following an extended outage, there must be a two-phase process to bring the system back live to the care providers—not an immediate return to ‘business as usual.’ Phase 1 should address census reconciliation in the EHR where the Admission-Discharge-Transfer changes must be made to accurately account for patients treated. Phase 2 will recommence normal operations once the updating and accurate accounting of the inhouse patients has taken place towards:

  • Documentation recaptured or entered for patients currently in-house is a priority in Phase 2 for care delivery versus those that have been discharged, but nonetheless urgent as entries which will be needed for ROI.
  • Medical record documents must be HIM-analyzed for deficient or missing documentation
  • Post-outage document image scanning volumes will be quadrupled—paper-based medical record documents generated during the outage must be quickly converted to EHR documentation that is needed for follow-up patient care
  • EHR documentation of the outage in ‘live’ patient records must be flagged to indicate that notes/orders/tests chronology was disrupted, and scanned images should be referenced in a different tab
  • ROI requests will triple when the patient population shifts to non-devastated areas away from the disaster. Health information access is necessary to inform clinical decision-making (e.g., during northern California wildfires involving mass evacuations, facilities and pharmacies were inundated with inquiries regarding medication prescriptions).
  • Revenue cycle cash flow sustainability, as a result of delayed coding/billing will be treacherous, and highly reliant on clinical documentation that needs to be swiftly restored in the EHR
Disaster Anticipation is Essential

Information governance is a proactive approach that ensures readiness when there is a sudden, pressing need to quickly access medical record documentation for efficient care delivery. In addition to a swift fallback process to capture care documentation, implementing a strong HIM and IT infrastructure that provides secure access to back-up clinical information EHRs will avoid crippling effects of delayed care and patient safety risks. It is critical that the disaster recovery plan is communicated to all staff and is updated as needed to ensure the most effective plan will be used when the “BIG ONE” strikes. This approach will help healthcare organizations avoid risk, avoid costs, remain calm, and keep the focus on delivering excellent patient care.

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